Provider Demographics
NPI:1073008835
Name:ORTIZ, JACKLYN R (RBT)
Entity Type:Individual
Prefix:MS
First Name:JACKLYN
Middle Name:R
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30300 ANTELOPE RD APT 1713
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-9567
Mailing Address - Country:US
Mailing Address - Phone:951-287-8760
Mailing Address - Fax:
Practice Address - Street 1:26720 YNEZ CT
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4659
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician